(A)
A
managed care plan(MCP) must
ensure each member has a primary care provider (PCP) who will serve as an
ongoing source of primary care and assist with care coordination appropriate to
the member's needs.

(1)
An MCP must ensure PCPs are in compliance with the
following triage requirements:

(a)
Members
with emergency care needs must be triaged and treated immediately on
presentation at the PCP site;

(b)
Members with persistent symptoms must be treated no later than the end of the
following working day after their initial contact with the PCP site;
and

(c)
Members with requests for
routine care must be seen within six weeks.

(2)
PCP care coordination responsibilities
include at a minimum the following:

(a)
Assisting with coordination of the member's overall care, as appropriate for
the member;

(b)
Providing services
which are medically necessary as described in rule
5160-1-01 of the Administrative
Code;

(B)
An MCP must have a
utilization management (UM) program with clearly defined structures and
processes designed to maximize the effectiveness of the care provided to the
member. An
MCP must ensure decisions rendered through the UM program are based on
medical necessity.

(1)
The UM program must be
based on written policies and procedures that include, at a minimum :

(a)
The information sources used to
make determinations of medical necessity;

(b)
The criteria, based on sound clinical
evidence, to make UM decisions and the specific procedures for appropriately
applying the criteria;

(c)
A
specification that written UM criteria will be made available to both
contracting and non-contracting providers; and

(d)
A description of how the MCP will monitor
the impact of the UM program to detect and correct potential under- and
over-utilization.

(b)
The involvement of a
designated senior physician in the UM program.

(c)
The use of appropriate qualified licensed
health professionals to assess the clinical information used to support UM
decisions.

(d)
The use of
board-certified consultants to assist in making medical necessity
determinations, as necessary.

(e)
That UM decisions are consistent with clinical practice guidelines as specified
in rule 5160-26-05.1 of the Administrative Code. An
MCP
may not impose conditions around the coverage of a medically necessary
medicaid-covered service unless they are supported by such clinical practice
guidelines.

(f)
The reason for each
denial of a service, based on sound clinical evidence.

(g)
That compensation by the MCP to
individuals or entities that conduct UM activities does not offer incentives to
deny, limit, or discontinue medically necessary services to any member.

(3)
An MCP must process requests for initial and continuing
authorizations of services from their providers and members.
An MCP must have written policies and procedures to
process requests and, upon request, the MCP's policies and procedures must be
made available for review by the Ohio department of
medicaid (ODM). The MCP's written policies
and procedures for initial and continuing authorizations of services must also
be made available to contracting and non-contracting providers upon request.
The MCP
must ensure and document the following occurs when processing requests for
initial and continuing authorizations of services:

(c)
Any decision to deny a service
authorization request or to authorize a service in an amount, duration, or
scope that is less than requested, must be made
by a health care professional who has appropriate clinical expertise in
treating the member's condition or disease.

(d)
That a written notice will be sent to the
member and the requesting provider of any decision to reduce, suspend,
terminate, or deny a service authorization request, or to authorize a service
in an amount, duration, or scope that is less than requested. The notice to the
member must meet the requirements of division 5101:6 and rule
5160-26- 08.4 of the Administrative Code.

(e)
For standard authorization decisions, the
MCP must provide notice to the provider and member as expeditiously as the
member's health condition requires but no later than ten calendar
days following receipt of the request for service, except as specified in
paragraph (B)(3)(g) of this rule. If requested by the member, provider, or MCP,
standard authorization decisions may be extended up to fourteen additional
calendar days. If requested by the MCP, the MCP must submit to ODM for
prior-approval, documentation as to how the extension is in the member's
interest. If ODM approves the MCP's extension request, the MCP must give the
member written notice of the reason for the decision to extend the time frame
and inform the member of the right to file a grievance if he or she disagrees
with that decision. The MCP must carry out its determination as expeditiously
as the member's health condition requires and no later than the date the
extension expires.

(f)
If a
provider indicates or the MCP determines that following the standard
authorization timeframe could seriously jeopardize the member's life or health
or ability to attain, maintain, or regain maximum function, the MCP must make
an expedited authorization decision and provide notice of the authorization
decision as expeditiously as the member's health condition requires but no
later than forty-eight hours after receipt of the request
for service. If requested by the member or MCP, expedited authorization
decisions may be extended up to fourteen additional calendar days. If requested
by the MCP, the MCP must submit to ODM for prior-approval, documentation as to
how the extension is in the member's interest. If ODM approves the MCP's
extension request, the MCP must give the member written notice of the reason
for the decision to extend the timeframe and inform the member of the right to
file a grievance if he or she disagrees with that decision. The MCP must carry
out its determination as expeditiously as the member's health condition
requires and no later than the date the extension expires.

(g)
Service authorization decisions not
reached within the timeframes specified in paragraphs (B)(3)(e) and (B)(3)(f)
of this rule constitute a denial, and the MCPs must give notice to the member
as specified in rule
5160-26-08.4 of the Administrative Code.

(h)
Prior authorization decisions for covered
outpatient drugs as defined in
42 U.S.C.
1396r-8(k)(2) (as in effect
January 1, 2017) must be made by telephone or other telecommunication device
within twenty-four hours of the initial request. When an emergency situation
exists, a seventy-two hour supply of the covered outpatient drug that was
prescribed must be authorized. If the MCP is unable to obtain the information
needed to make the prior-authorization decision within seventy-two hours, the
decision timeframe has expired and the MCP must give notice to the member as
specified in rule
5160-26-08.4 of the Administrative Code.

(i)
MCPs must maintain and submit as directed
by ODM, a record of all authorization requests, including standard and
expedited authorization requests and any extensions granted. MCP records must
include member identifying information, service requested, date initial request
received, any extension requests, decision made, date of decision, date of
member notice, and basis for denial, if applicable.

(4)
MCPs must implement the ODM-required
emergency department diversion program for frequent users.

(5)
Pursuant to section
5167.12 of the Revised Code,
an MCP
may, subject to ODM prior approval, implement strategies for the management of
drug utilization. At a minimum, an MCP must implement a coordinated services program
(CSP) as described in rule
5160-20-01 of the Administrative
Code. An MCP must
offer care management services to any member enrolled
in CSP.

(6)
An MCP
may develop other UM programs subject to ODM
prior approval.